Provider Demographics
NPI:1568685493
Name:MACKIN, SUSAN MARY (MA, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY
Last Name:MACKIN
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1046
Mailing Address - Country:US
Mailing Address - Phone:219-322-8560
Mailing Address - Fax:219-322-8570
Practice Address - Street 1:925 SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1046
Practice Address - Country:US
Practice Address - Phone:219-322-8560
Practice Address - Fax:219-322-8570
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23001111A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02484OtherNECP
IN408440AMedicare ID - Type Unspecified